Living Well with Myeloma Teleconference Series Thursday, March 24 th 216 4: PM Pacific/5: PM Mountain 6: PM Central/7: PM Eastern
Speakers Dr. Brian Durie, IMF Chairman Cedars Sinai Samuel Oschin Cancer Center Los Angeles, CA Dr. Rafat Abonour Indiana University Simon Cancer Center Indiana, IN Dr. Vincent Rajkumar Mayo Clinic Rochester, MN 2
Top Questions Needing Answers Episode 1! 1. How to use newly approved agents: Farydak (panobinostat) Darzalex (daratumumab) Ninlaro (ixazomib) Empliciti (elotuzumab) 2. Are CAR-T cells the future best therapy? International Myeloma Foundation 3
Agents for Discussion Today Agent Use Combination Farydak (panobinostat) Relapse/Refractory + Velcade / Dexamethasone Darzalex (daratumumab) Ninlaro (ixazomib) Relapse/Refractory 1 prior regimen Single agent + Revlimid / Dexamethasone Empliciti (elotuzumab) Relapse: 1-3 prior regimens + Revlimid / Dexamethasone International Myeloma Foundation 4
The Decision Process* Clinical experience Data from research DECISION EVIDENCE-BASED MEDICINE Sackett DL & al., «Evidence based medicine: what it is and what it isn't» BMJ, vol. 312, no 723, janvier 1996 International Myeloma Foundation Patient preferences *Philippe Moreau ASH 215 5
Treatment Approaches in Relapsed/Refractory MM First relapse Participate in clinical trials with novel agents IMiD-based regimen Underlying PN Prior IMiD use with durable/deep response Prior bortezomib use PI-based regimen Prior IMiD use Prior bortezomib use with durable/deep response Translocation (4;14) Autologous transplant Long remission post 1st transplant (>18 24 months) Transplant not part of primary therapy Len-naïve KRd, IRd Elo-Rd (high risk) Bor-naïve Kd, KRd, IRd Len/Bor-exposed Pano-Vd Usmani SZ, Lonial S. Clin Lymphoma Myeloma Leuk. 214;14 Suppl:S71. 6
Treatment Approaches in Relapsed/Refractory MM second relapse Participate in clinical trials with novel agents Chemotherapy for rapid relapse IMiD- or PI-based regimen Transplant VTD-PACE, DT-PACE, DCEP Especially for extramedullary disease, secondary plasma cell leukemia Carfilzomib/ Dex ± IMiD Pomalidomide/ Dex ± PI PI preference for translocation (4;14) Autologous: usually a short-term fix Allogeneic: for select group, in a clinical trial setting Dual (Len/Bor) refractory OR >3 prior Lines Daratumumab Usmani SZ, Lonial S. Clin Lymphoma Myeloma Leuk. 214;14 Suppl:S71. 7
Summary of Combination Therapy at Relapse RD* 1 ORR 6 Median Lines of Tx: KRd* 2 RVD* 3 64 87 2 PVd 4 85 Vd* 5 CyBorD 6 67 71 3 CRD 7 CPd 8 65 65 4 Pd* 9 31 Kd 1 KPd 11 2 55 4 6 ORR (%) 7 8 1 5 *Data from phase 3 trials, all others from phase 1 or 2 trials 1. Dimopoulos M et al. N Engl J Med. 27;357:2123. 2. Stewart AK et al. N Engl J Med. 215;372:142. 3. Richardson PG et al. Blood. 214;123:1461. 4. Lacy MQ et al. Blood. 214. Abstract 34. 5. Mikhael JR et al. Br J Haematol. 29;144:169. 6. Monge J et al. J Clin Oncol. 214. Abstract 8586. 7. Morgan GJ et al. Br J Haematol. 27;137:268. 8. Baz R et al. Blood. 214. Abstract 33. 9. San Miguel J et al. Lancet Oncol. 213;14:155. 1. Lendvai N et al. Blood. 214;124:899. 11. Shah JJ et al. Blood. 213. Abstract 69. 8
Summary of Combination Therapy at Relapse PFS/TTP RD* 1 11 NR Median Lines of Tx: OS KRd* 2 RVD* 3 1 26 3 33 2 PVd 4 11 NR CyBorD 6 9 29 3 CPd 8 1 NR 4 Pd* 9 4 13 Kd 1 4 2 5 KPd 11 1 2 5 1 15 2 Survival (Mos) 25 3 35 9
How to use Farydak (panobinostat) International Myeloma Foundation 1
PANORAMA1 Study Design 21-day cycles Randomization N=768 Stratification: Number of previous treatment lines Prior bortezomib Pano-Vd Panobinostat 2 mg Days 1, 3, 5, 8, 1, 12 Bortezomib 1.3 mg/m 2 Days 1, 4, 8, 11 Dexamethasone 2 mg Days 1, 2, 4, 5, 8, 9, 11, 12 Vd Bortezomib 1.3 mg/m 2 mg Days 1, 4, 8, 11 Dexamethasone 2 mg Days 1, 2, 4, 5, 8, 9, 11, 12 BOR NAÏVE OR BOR SENSITIVE San Miguel JF et al. Lancet Oncol. 214;15:1195. 11
PANORAMA1 Results Pano-Vd (n=387) Vd (n=381) HR P Value Median PFS, mos 12 8.1.63 <.1 ORR, % 6.7 54.6.9 ncr, % 27.6 15.7 <.1 IMiD + bortezomib, mos 1.6 5.8 -- -- IMiD + bortezomib + 2 prior lines, mos AEs, % 12.5 4.7 -- -- G3 Diarrhea 25 7 G3 Asthenia 24 12 G3 PN 17 15 Benefit less pronounced in women and patients > 65 years BUT more evident in patients who with previous exposure to bortezomib and immunomodulatory agent. San Miguel JF et al. Lancet Oncol. 214;15:1195. 12
Summary of Other Notable HDAC Combinations Outcomes Regimen Phase (N) ORR CBR Ricolinostat ± bortezomib + dexamethasone 1 1 (2) 25% (heavily pretreated) 6% (2 pts VGPR, 3 pts PR, 2 pts MR, 5 pts SD) Ricolinostat + lenalidomide + 1 (22) 64% dexamethasone 2 1% (1 pt CR, 5 pts VGPR, 8 pts PR, 3 pts MR, 5 pts SD) Panobinostat + carfilzomib + 1 (36) 77% dexamtheasone 3 88% (1 pt CR, 1 pts VGPR, 16 pts PR, 4 pts MR, 4 pts SD) 1. Raje N et al. Blood. 213;122. Abstract 759. 2. Raje N et al. EHA 214. Abstract P358. 3. Berdeja JG et al. J Clin Oncol. 215;33. Abstract 8513. 13
When do you recommend panobinostat? International Myeloma Foundation 14
Targets on the Myeloma Cell Surface SLAMF7 CD38 15
What s Dara? CD38 Daratumumab is an IV human IgG manufactured antibody It is a targeted immunotherapy which binds to CD38 16
Efficacy in Combined Analysis ORR, % 35 3 25 2 15 PR VGPR CR scr ORR = 31% 2% 1% 3% CR or better 13% 1% VGPR or better 1 18% 5 16 mg/kg N = 148 ORR was consistent in subgroups including age, number of prior lines of therapy, refractory status, or renal function 17
Progression-free Survival Patients progression-free and alive, % 1 75 5 25 Responders MR (Minimal Response)/SD (Stable Disease) PD (Progressive Disease)/NE (Non-Evaluable) Responders (Median ~7.4 months) MR/SD: 3.2 (2.8-3.7) months PD (median ~.9 months) Patients at risk Responders MR/SD PD/NE 46 77 25 2 4 6 8 1 12 14 16 18 2 46 45 41 21 Time from first dose, months 35 13 27 3 14 2 13 1 5 3 3 18
Overall Survival 1 Patients alive, % 75 5 Responders MR/SD 25 PD Responders MR/SD PD/NE Patients at risk Responders MR/SD PD/NE 46 77 25 2 4 6 8 1 12 14 16 18 2 22 46 74 16 46 67 12 Time from first dose, months 45 63 11 44 57 7 43 53 7 42 47 5 29 37 4 15 1 1 13 5 1 3 1 For the combined analysis, median OS = 19.9 months 1-year overall survival rate = 69% (95% CI, 6.4-75.6) 19
When do you recommend DARA? International Myeloma Foundation 2
What about Ixazomib (Ninlaro )? International Myeloma Foundation 21
TOURMALINE-MM1 Study Design 28-day cycles Randomization N=722 Stratification: Number of prior therapies PI exposure ISS stage IRd Ixazomib 4 mg Days 1, 8, 15 Lenalidomide 25 mg Days 1 21 Dexamethasone 4 mg Days 1, 8, 15, 22 Rd Lenalidomide 25 mg Days 1 21 Dexamethasone 4 mg Days 1, 8, 15, 22 LEN NAÏVE OR LEN SENSITIVE Moreau P et al. Presented at: 57th ASH Annual Meeting & Exhibition. Orlando, FL; December 215. Abstract 727. 22
TOURMALINE-MM1 Results I-Rd (n=36) Rd (n=362) HR P Value Median PFS, mos 2.6 14.7.742.12 ORR, % 78.3 71.5.35 VGPR, % 48.1 39..14 AEs, % G3 Diarrhea 6 2 G3 PN 2 2 Benefit with IRd was also noted in pts with high-risk cytogenetics. Moreau P et al. Presented at: 57th ASH Annual Meeting & Exhibition. Orlando, FL; December 215. Abstract 727. 23
When do you recommend Ixazomib (Ninlaro )? International Myeloma Foundation 24
What s Elo? Elotuzumab (HuLuc63) is an IV humanized monoclonal antibody targeting human SLAMF7, a cell surface glycoprotein. CD16 Elotuzumab Hsi ED et al. Clin Cancer Res. 28;14:2775-2784. Tai YT et al. Blood. 28;112:1329-1337. van Rhee F et al. Mol Cancer Ther. 29;8:2616-2624. Lonial S et al. Blood. 29;114:432. Richardson PG, et al. ASH 214. Abstract 32 25
ELOQUENT-2: Elotuzumab With Lenalidomide/Dexamethasone R/R MM Randomized, open-label, multicenter phase III trial Pts with relapsed MM and 1-3 prior treatments Elotuzumab 1 mg/kg IV QW cycles 1, 2 then Q2W + Lenalidomide 25 mg PO D1-21 + Dexamethasone 4 mg PO QW (n = 321) 28-day cycles (N = 646) Lenalidomide 25 mg PO D1-21 + Dexamethasone 4 mg PO QW (n = 325) Until Progression or unacceptable toxicity Primary endpoints: Progression Free time (PFS), Overall Response Secondary endpoints: Overall Survival, safety, health-related Quality of Life Dimopoulos MA, et al. ASH 215. Abstract 28. 6 26
ELOQUENT-2: Progression Free and Overall Response Probability Progression Free Response Rate (%) 1..8.6.4.2 4 8 12 16 2 24 28 32 36 Mos P =.2 1 Elo-Rd Rd 8 79 66 6 4 2 ORR* 1-yr PFS 68% 57% 33 28 Combined Response (scr + CR + VGPR) 2-yr PFS 4 41% 27% 7 CR (scr + CR ) 28 21 46 38 VGPR Elo-Rd Rd Median PFS, mos 19.4 14.9 (95% CI) (16.6-22.2) (12.1-17.2) PR Lonial S, et al. N Engl J Med 215; 373:621-631 Elo-Rd Rd 27
When do you recommend Elo? International Myeloma Foundation 28
CAR T Immune Therapy 29
T cells CAR-T are white blood cell cells therapy that attack and 11 kill viruses and cancer cells I hope Chimeric antigen receptors (CARs) help T-cells recognize and destroy cancer cells 1. T cells are collected from the patient. A machine removes the desired cells from the blood, then returns the rest back to the patient. 3
CAR-BCMA T Cells in Myeloma: Background T cells can be genetically modified to express chimeric antigen receptors (CARs) specific for malignancy-associated antigens B-cell maturation antigen (BCMA) is expressed by normal and malignant plasma cells. BCMA is a potential target for CAR T-cell therapy for MM T Cell AntiBCMA T Cell AntiBCMA T Cell AntiBCMA T Cell AntiBCMA The patient s own T-cells were stimulated, transduced with CAR-BCMA retroviruses, and cultured for 9 days before infusion. Study presented ASH 215 evaluated CAR- BCMA T cell infusion for treatment of advanced MM 1. Carpenter RO, et al. Clin Cancer Res. 213;19:248-26. Ali SA, et al. ASH 215. Abstract LBA-1. 31
CAR-BCMA T Cells in Myeloma: Study Design First-in-human phase I trial Pts with advanced relapsed/ refractory MM More than 3 prior lines of therapy; BCMA expression on myeloma cells 12 patients enrolled Cyclophosphamide 3 mg/m 2 Fludarabine 3 mg/m 2 QD for 3 days CAR-BCMA T cells* Single infusion *Dose escalation of CAR+ T cells/kg.3 x 1 6 1. x 1 6 3. x 1 6 9. x 1 6 Ali SA, et al. ASH 215. Abstract LBA-1. 32
CAR-BCMA T Cells in Myeloma: Response to therapy Response to Therapy Stringent complete response(scr) Number of Patients (total 12 treated) 1 Very good partial response VGPR 1 Partial response 2 Stable disease 8 Ali SA et al. Proc ASH 215;Abstract LBA1. 33
SO: Are CAR-T cells worth all the hype? Does high risk make a difference? What other therapies can play an important role? International Myeloma Foundation 34
Support International Myeloma Foundation 35
International Myeloma Foundation